Leveraging Health Official Authority and Influence for Systems Improvement

July 31, 2022

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Areas where public health leaders are authorized to act. For example, public health has the authority to create and implement strategic plans and performance monitoring systems.


Areas where public health leaders can encourage action by another party. For example, public health has influence in recommending data to human services or transportation authorities to support community health improvements.

Systems Improvement

Efforts to strengthen and improve the interdependence of cross- sector partners, rocesses, or events that work toward a common goal.

Health officials are uniquely positioned within state/territorial governments to exercise their influence and designated authority to affect change and systems improvement across public health sectors. This brief draws on health officials’ experiences in territories and freely associated states to illustrate opportunities to lead improvement efforts by building relationships, committing to data use, establishing regular communication, and investing in workforce development.


Health officials enter their roles with varying levels of experience in governmental, business, community, and clinical settings. The diverse perspectives they bring are an asset in leading a health department and implementing systems improvement strategies. A challenge for health officials is that they may be term-limited and politically appointed. They therefore have limited time in their role and must adapt quickly. Given resources constraints and many priorities, public health must prioritize health enhancement versus disease management. With this commitment, health officials can focus on improvements that most impact primary prevention and structural change.

First, in territories and Freely Associated States, gaps in human resources and administrative systems delay health officials’ ability to address challenges and invest in well-built systems. One key “human system” is the well-being of leaders, who can face physical and mental exhaustion. As health officials cope with issues both big and small, they must invest in themselves and their staff to prevent burn out.

Second, by starting with the authority and influence for workforce development, health officials can build on their unique position to influence organizational and systems change that impacts health outcomes. ASTHO discussed these themes with current and former health officials in Freely Associated States and compiled and categorized a list of systems improvements strategies as areas for authority and/or influence.

The resulting table draws heavily on the experiences of former Secretary of Health of the Federated States of Micronesia Vita Skilling, MD, and Senator of Palau Stevenson Kuartei, MD, who note that authority and influence can exist on a spectrum and may evolve over the course of tenure, or depending on changes in the field. The table includes example strategies used for systems improvement. To determine which strategies are appropriate in each jurisdiction, leadership should consider the agency’s readiness to manage change and at what scale change can be sustained.

Words from Contributing Authors

In reflecting on the authority and influence of health officials to improve systems, Skilling and Kuartei shared the following statements and acknowledged the many partners who have supported their work.

Dr. Stevenson Kuartei on Where to Start

“The distinction between disease management (disease treatment and prevention) and health enhancement (health promotion and protection) is important because it allows for balanced advocacy (influence) and alignment of resources and expertise (authority).”

“Leveraging authority and influence to advance systems improvement must begin by clarifying and prioritizing the systems that need improvement. In the freely-associated states, there are fundamental issues that make it hard to appropriately and effectively exert authority or influence on systems. [...] continuous and cyclic strategic planning (plan, implement, study, assess) is not a regular part of the health management culture. This ‘disorganization’ leads to mis-targeted authority and influence.”

Dr. Vita Skilling on Managing Self and Staff

“There is a risk of physical and mental exhaustion with this job [and] there must be ways to deal and cope with the issues both big and small to prevent ‘premature burn out’ and/or ‘giving up’ in the process.”

“[Professional licensing can help] to reduce ‘professional isolation’ for staff who are complacent about keeping up with state of art and skills in their fields, including the health assistants on the remote islands and for staff who earned their positions through hands on training but did not have the formal education for them.”

“It is almost impossible to check and respond to communications, accommodate the traffic through an open door policy, and still complete self- and management learning. Therefore, [I designated] 2 half days a week as my catch up days. The Executive Secretary manages these days... allowing the Secretary to catch up... on ‘first things first basis’.”

Example Strategies Used for Systems Improvement

Table 1. Self and Staff Support

Self and Staff Support Authority Influence
Strengthen personal resilience and time management x x
Establish a conflict resolution committee to assist with certain situations x  
Implement a healthy foods policy x x
Implement a mother/baby policy to allow breastfeeding and childcare rooms in departments x x
Incorporate fitness during the workday   x
Establish an employee support committee x  

Table 2. Human Resource Planning and Development

Human Resource Planning and Development Authority Influence
Commit to training and retraining to promote staff proficiency x  
Implement an efficient hiring process x  
Increase National Government Personnel Partnership for salary adjustments   x
Implement an organizational structure to reduce risk of staff turnover   x
Implement longer-term workforce planning and development   x
Establish partnerships with educational institutions x  

Table 3. Quality Improvement

Quality Improvement Authority Influence
Commit to strategic planning x  
Increase data management and finance training with partnership institutions x x
Implement an administrative services rotation to increase management skills x  
Establish a sharing of skills, activities, and duties among staff x  

Table 4. Quality Assurance

Quality Assurance Authority Influence
Require licensing and continuing education for all levels of health professionals x x
Implement written protocols/Standard Operating Procedures in all areas x x
Establish licensing for all newly established clinics and reevaluate existing clinics with Standard Operating Procedures x x

Table 5. Administrative Support

Administrative Support Authority Influence
Implement management committees to support policy and system reviews x  
Implement communication protocols x  
Implement a healthy workload balance to accomplish projects while being accessible to staff (e.g., an open-door policy) x x

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Acknowledgements and Appreciation of Partners

Cancer Council of the Pacific Islands, Department of the Interior—Office of Insular Affairs, Federated States of Micronesia Directors of Health, Fiji National University, National Public Health and Hospital Institute, Pacific Island Health Officers Association, Pacific Ministers of Health, Palau Ministry of Health, Secretariat of the Pacific Community, United Nations agencies including the World Health Organization, CDC, HHS Region IX, World Women Leaders.